Ithaca School District
Referral for Intervention Team Meeting
PERSONAL INFORMATION:
Student:_____________________________________
D.O.B.:________________________________
Grade: ___________Parents/Guardians:______________________________________________________
Address:________________________________________
Phone: ________________________________
Referring Adult:__________________________________
PREREQUISITES FOR INTERVENTION TEAM MEETING:
I have contacted the parent/guardian via phone call on:
I have consulted with fellow staff members (including the student’s previous teachers) to identify suggestions
and modifications.
I have read the student’s cumulative file. Date:
DATA FOR INTERVENTION TEAM MEETING:
Academic Functioning:
Please complete the table below. Please include specific scores as well as the proficiency level (if applicable). In the
area of “Other Curriculum Assessments,” include the specific target skill rather than a letter grade. Attach as needed.
See
Attached
Report
Assessment
K Probes/ Report Card
Skills
DIBELS
PALS
STAR Reading
STAR Math
Fountas and Pinnel
Leveled Assessment
OTHER
Revised 4/1/2014
Administration
Date(s)
Student Performance
Level(s)
Expected Student
Performance Level(s)
Social/Emotional/Behavioral Functioning (complete for students with behavioral concerns):
Please complete the table below. Provide specific concerns regarding behavior and define the discrepancy
between the student’s actions to that of an average student’s behavior.
Date
Specific Behavior Exhibited
Frequency
Duration
Attendance/Tardiness:
Any concerns regarding attendance or tardiness?
Year
Grade
# of Days Absent
No
# of Tardies
Yes – Complete table below for last two school years
Consequence
Previous Interventions:
What have you already tried to address your concerns? Please list interventions that have been attempted during Tier 2,
the duration, and the outcome using the table below. Attach as needed.
Intervention*
Date
Begun
Date
Ended
Data Collected
Attach if necessary
Staff Member
Conducting
Intervention
*See Reading Specialist or School Psychologist for ideas if needed
Please submit this completed and signed form to Maggie May, School Psychologist.
Signature of Person Making Referral: ________________________________
Date:____________
Recipient Signature:______________________________________________ Date Received:___________
Revised 4/1/2014